Abstract
Background
Due to the increasing use of alternative tobacco products (waterpipes, heat-not-burn) and tobacco alternatives (e-cigarettes), we studied recent changes in the prevalence of conventional tobacco use and alternative products.
Methods
Data come from ten waves of the Epidemiological Survey of Substance Abuse (ESA) from 1995 to 2021, with representative samples collected via paper-pencil questionnaires, telephone interviews, or online. We compared the prevalence of conventional tobacco use and alternative products by gender and age (18–24, 25–39, 40–59 years).
Results
In all age groups, the use of conventional tobacco products decreased. The prevalence of the exclusive use of one of the three alternative products differed statistically significantly between age groups and in 2021 was higher for ages 18–24 (females: 11.1%, males: 12.4%) compared to ages 25–39 (females: 2.9%; males: 4.9%) and ages 40–59 (females: 1.4%; males: 2.0%). The use of alternative products was mainly due to the exclusive use of waterpipes among individuals aged 18 to 24 and 25 to 39 and the exclusive use of e-cigarettes among individuals aged 40 to 59.
Conclusions
The higher prevalence of alternative product use among young adults implies a turning point that needs to be considered in prevention. Because of the addictive potential of these products, young adults can be expected to maintain their use into middle and older adulthood. There is a need to monitor the use of alternative products, identify the risks associated with them, and develop effective prevention and cessation interventions for adults.
Tobacco use is one of the dominant risk factors worldwide for premature mortality and years of life lost due to sickness and disability (1). For 2019, the percentage of all deaths attributable to the use of tobacco in 204 countries and territories was estimated to be 20.2% for men and 5.8% for women (2). Forecasts predict at least one billion tobacco-related deaths in the 21st century if prevalence remains unchanged (3). Since 1990, a decline in prevalence has been observed among men (27.5%) and women (37.7%) aged 15 years and older (2). A decline in tobacco use has also been reported in Germany. Trend analyses for the period 1995–2018 in adults aged 18–59 years show a decline from 42.8% to 24.2% among men and from 29.3% to 22.5% among women (4).
However, the available trend analyses only consider the use of cigarettes, cigars, cigarillos, or pipes (4), and neglect the use of alternative tobacco products such as waterpipes and heat-not-burn, as well as tobacco alternatives (electronic cigarettes [e-cigarettes]). There has been a significant increase in the variety and advertising of these products in recent years, and they are becoming ever more popular, especially among adolescents and young adults (5– 7). The growing interest in these products is attributed to, among other factors, the variety of flavors available, social acceptance, and the potentially lower health risks (6– 8).
However, recent literature reviews highlight the fact that the use of these products brings with it significant health risks (5, 9– 13). The use of waterpipes is associated with more intensive exposure to largely the same toxins as those in conventional cigarettes, meaning that waterpipe smoking is considered to be more harmful to health than the use of conventional cigarettes (14). Furthermore, waterpipe use is associated with a similar level of oxidative stress compared to conventional cigarettes, which can lead to irreversible chronic damage to the cardiovascular and respiratory systems, as well as various types of cancer, and is thus associated with an increased risk of mortality (5, e1).
The liquids in e-cigarettes contain propylene glycol and/or glycerin. E-cigarettes also have a variety of added flavors and may contain nicotine. Since the liquids are vaporized, the aerosol contains significantly lower levels of harmful substances such as formaldehyde, acetaldehyde, and acrolein compared to conventional cigarette use (15). With regard to the negative health effects of e-cigarettes, the evidence is mixed (6, 16). However, e-cigarettes can assist smoking cessation (17, e2) and demonstrate similar or better effectiveness compared to nicotine replacement products (18). Having said that, a recent meta-analysis comparing e-cigarettes with nicotine replacement therapy suggests that the use of e-cigarettes as an intervention for smoking cessation can lead to permanent nicotine dependence (19). The evidence with regard to heat-not-burn products is currently too sparse to make reliable statements on their health effects. However, recent studies report lower health risks for heat-not-burn products compared to conventional cigarettes (7). Since alternative tobacco products may contain nicotine, there is a particular risk that their use could lead to the development of dependence (20).
Survey data from Germany point to a decline in the use of conventional cigarettes in all age groups (4). Whereas the use of e-cigarettes, waterpipes, and heat-not-burn products among adolescents and young adults has increased (21), the prevalence rates of use of heat-not-burn products and e-cigarettes among adults are comparatively low (22). The high level of popularity of waterpipes among 11- to 17-year-olds is reflected in the 8.5% prevalence estimate of current use (23). Thus, there is evidence to suggest that an evaluation of the declining trend in the use of conventional tobacco products should take into consideration the increasing prevalence of alternative tobacco product use and e-cigarette use. From a public health perspective, the successes of tobacco prevention in recent decades may be undermined by the use of alternative tobacco products and tobacco alternatives (6, 24).
The aim of this article is to analyze changes over time in gender-specific prevalence rates of tobacco use, alternative tobacco products, and tobacco alternatives by age groups.
Methods
Study design and samples
Data come from 10 waves of the German Epidemiological Survey of Substance Abuse (Epidemiologische Suchtsurvey, ESA) from 1995 to 2021 (every third year from 1997 onwards). In each wave, the baseline population comprised the German population aged 18–59 years (since 2006, 18–64 years). Data were collected using a combination of methods, including written and internet-based surveys as well as telephone interviews. With a response rate of between 35% (2021) and 65% (1995 and 1997), the sample size of the individual surveys ranged from 7833 (1995) to 9267 (2018). Due to the change in age range in 2006, data for 18- to 59-year-olds were used for the analyses. Details of the respective study designs are presented in eTable 1.
eTable 1. Overview of the German Epidemiological Survey of Substance Abuse (1995–2021).
| Year | n | Age | Response rate | Design | Mode | Reference |
| 2021 | 9046 | 18–64 Y | 35% | Sample of registered residents,disproportionate sampling, initial contact by post; German-speaking population | Written/telephone/internet | Rauschert et al., 2022 (e5) |
| 2018 | 9267 | 18–64 Y | 42% | Sample of registered residents,disproportionate sampling, initial contact by post; German-speaking population | Written/telephone/internet | Atzendorf et al., 2019 (e6) |
| 2015 | 9204 | 18–64 Y | 52% | Sample of registered residents,disproportionate sampling, initial contact by post; German-speaking population | Written/telephone/internet | Piontek & Kraus, 2016 (e7) |
| 2012 | 9084 | 18–64 Y | 54% | Sample of registered residents,disproportionate sampling, initial contact by post; German-speaking population | Written/telephone/internet | Kraus, Piontek, Pabst & Gomes de Matos, 2013 (e8) |
| 2009 | 8030 | 18–64 Y | 50% | Sample of registered residents,disproportionate sampling, initial contact by post; German-speaking population | Written/telephone/internet | Kraus & Pabst, 2010 (e9) |
| 2006 | 7912 | 18–64 Y | 45% | Sample of registered residents,disproportionate sampling, initial contact by post; German-speaking population | Written/telephone | Kraus & Baumeister, 2008 (e10) |
| 2003 | 8061 | 18–59 Y | 55% | Sample of registered residents,disproportionate sampling, initial contact by post; German-speaking population | Written | Kraus & Augustin, 2005 (e11) |
| 2000 | 8139 | 18–59 Y | 51% | Sample of registered residents, age-proportional sampling, questionnaire sent by post; German-speaking population | Written | Kraus & Augustin, 2001 (e12) |
| 1997 | 8020 | 18–59 Y | 65% | Random route; ADM design (German federalelectoral districts); age-proportional sampling; questionnaire delivered in person; German- speaking population | Written | Kraus & Bauernfeind, 1998 (e13) |
| 1995 | 7833 | 18–59 Y | 65% | Random route; ADM design (German federalelectoral districts); age-proportional sampling; questionnaire delivered in person; German- speaking population | Written | Herbst, Kraus & Scherer, 1996 (e14) |
ADM design, sample design of the Working Group of German Market and Social Research Institutes (Arbeitskreis Deutscher Marktforschungsinstitute); Y., years
Instruments
The use of relevant products at least once in the 30 days prior to the survey was taken into consideration. The use of conventional tobacco products was surveyed from 1995 onwards, the use of e-cigarettes from 2015 onwards, as well as the use of waterpipes and heat-not-burn products from 2018 onwards. In the case of e-cigarettes, the survey was restricted to the use of e-liquids containing nicotine. The wording of the questions can be found in the eMethods Section.
Analyses
Prevalence rates for the use of conventional tobacco products were subdivided into exclusive use and the use of these products as well as at least one other alternative product during the same period of time. The sum of these two values was added up to yield the overall prevalence of conventional tobacco product use. Accordingly, the prevalence rates of exclusive use of the three alternative products were calculated, as was the prevalence of the use of at least one of these products. These prevalence rates are added up to yield the overall prevalence of alternative product use. The percentage of missing values varies between 0.1% and 6.5% (eTable 2). In order to match the distribution of sociodemographic characteristics of the sample to the population, data were weighted according to state, municipality size class, gender, and year of birth. Differences in prevalence were tested with Chi2 tests. Standard errors were calculated taking into account the multistage selection process using Taylor series (e3). The significance level was set at α = 0.05. All analyses were performed using Stata/SE 15.1.
eTable 2. Sample size and percentage of missing values by survey year, gender, and age.
| Age | |||||||||
| 18–24 Years | 25–39 Years | 40–59 Years | Total | ||||||
| Survey year | n | %mis | n | %mis | n | %mis | n | %mis | |
| Women | 1995 | 401 | 0.2% | 1883 | 0.1% | 1992 | 0.0% | 4276 | 0.0% |
| 1997 | 450 | 0.0% | 1878 | 0.1% | 1965 | 0.3% | 4293 | 0.1% | |
| 2000 | 556 | 0.4% | 1740 | 0.7% | 2159 | 1.9% | 4455 | 1.2% | |
| 2003 | 1077 | 1.0% | 1605 | 0.9% | 1768 | 1.8% | 4450 | 1.3% | |
| 2006 | 1017 | 0.3% | 1272 | 0.3% | 1628 | 1.2% | 3917 | 0.7% | |
| 2009 | 1135 | 0.2% | 1482 | 0.3% | 1472 | 1.3% | 4089 | 0.6% | |
| 2012 | 1154 | 0.4% | 1405 | 0.6% | 2002 | 0.6% | 4561 | 0.6% | |
| 2015 | 1236 | 0.9% | 1467 | 0.8% | 1852 | 1.0% | 4555 | 0.9% | |
| 2018 | 1223 | 7.4% | 1548 | 8.1% | 1801 | 4.9% | 4572 | 6.6% | |
| 2021 | 1175 | 1.6% | 1580 | 2.3% | 1846 | 2.4% | 4601 | 2.2% | |
| Total | 9424 | 1.5% | 15 860 | 1.4% | 18 485 | 1.5% | 43 769 | 1.5% | |
| Men | 1995 | 390 | 0.0% | 1366 | 0.1% | 1801 | 0.1% | 3557 | 0.1% |
| 1997 | 450 | 0.2% | 1494 | 0.1% | 1783 | 0.1% | 3727 | 0.1% | |
| 2000 | 413 | 1.0% | 1306 | 0.9% | 1965 | 1.4% | 3684 | 1.2% | |
| 2003 | 814 | 0.7% | 1205 | 0.6% | 1592 | 0.9% | 3611 | 0.8% | |
| 2006 | 868 | 0.5% | 934 | 0.2% | 1297 | 1.5% | 3099 | 0.8% | |
| 2009 | 922 | 0.3% | 1129 | 0.4% | 1183 | 0.3% | 3234 | 0.3% | |
| 2012 | 988 | 0.3% | 891 | 0.1% | 1552 | 0.6% | 3431 | 0.4% | |
| 2015 | 1149 | 0.3% | 1140 | 0.7% | 1412 | 1.2% | 3701 | 0.8% | |
| 2018 | 1032 | 5.9% | 1264 | 7.1% | 1440 | 4.9% | 3736 | 5.9% | |
| 2021 | 952 | 2.1 % | 1212 | 1.3% | 1328 | 2.3% | 3492 | 1.9% | |
| Total | 7978 | 1.3% | 11 941 | 1.2% | 15 353 | 1.3% | 35 272 | 1.3% | |
n, Sample size;%mis, percentage of missing values
Results
Sample sizes and the 30-day prevalence of the use of conventional tobacco products, waterpipes, heat-not-burn products, and e-cigarettes are shown in eTables 3– 5. The prevalence rates of the use of conventional tobacco products—separately for exclusive tobacco use and use in combination with one of the alternative products—the exclusive use of either e-cigarettes, waterpipes, or heat-not-burn products, and the use of two or more alternative products are shown for both genders and the age groups 18–24, 25–39, and 40–59 years in Figures 1– 3. The individual prevalence rates per year were added up to make the overall prevalence of the use of tobacco and alternative products.
eTable 3. Sample size and 30-day prevalence [95% confidence interval] of the use of conventional tobacco products and alternative products (from 2015) by survey year and gender; age 18–24 years.
| Conventional tobacco | E-cigarette | Waterpipe | Heat-not-burn product | |||||||
| Survey year | ncc | % | 95% CI | % | 95% CI | % | 95% CI | % | 95% CI | |
| Women | 1995 | 400 | 33.1 | [28.0; 38.7] | – | – | – | – | – | – |
| 1997 | 450 | 36.4 | [30.9; 42.2] | – | – | – | – | – | – | |
| 2000 | 554 | 39.6 | [35.5; 43.8] | – | – | – | – | – | – | |
| 2003 | 1066 | 39.7 | [37.0; 42.5] | – | – | – | – | – | – | |
| 2006 | 1014 | 37.8 | [34.9; 40.8] | – | – | – | – | – | – | |
| 2009 | 1133 | 30.1 | [27.3; 33.0] | – | – | – | – | – | – | |
| 2012 | 1149 | 23.5 | [21.0; 26.2] | – | – | – | – | – | – | |
| 2015 | 1225 | 19.4 | [17.4; 21.5] | 1.8 | [1.2; 2.7] | – | – | – | – | |
| 2018 | 1133 | 17.3 | [15.2; 19.6] | 4.0 | [3.0; 5.4] | 13.5 | [11.5; 15.8] | 0.6 | [0.3; 1.3] | |
| 2021 | 1156 | 15.5 | [13.4; 17.9] | 5.3 | [4.2; 6.8] | 14.7 | [12.5; 17.2] | 1.2 | [0.7; 2.1] | |
| Men | 1995 | 390 | 50.2 | [44.5; 55.9] | – | – | – | – | – | – |
| 1997 | 449 | 45.4 | [39.9; 50.9] | – | – | – | – | – | – | |
| 2000 | 409 | 45.4 | [40.9; 50.1] | – | – | – | – | – | – | |
| 2003 | 808 | 42.0 | [38.4; 45.8] | – | – | – | – | – | – | |
| 2006 | 864 | 41.5 | [37.8; 45.3] | – | – | – | – | – | – | |
| 2009 | 919 | 37.4 | [34.4; 40.5] | – | – | – | – | – | – | |
| 2012 | 985 | 29.8 | [26.9; 32.9] | – | – | – | – | – | – | |
| 2015 | 1145 | 28.4 | [25.8; 31.2] | 3.0 | [2.2; 4.1] | – | – | – | – | |
| 2018 | 971 | 23.6 | [21.2; 26.2] | 8.0 | [6.4; 9.9] | 22.4 | [19.6; 25.4] | 4.1 | [2.8; 5.8] | |
| 2021 | 932 | 22.0 | [19.0; 25.3] | 7.3 | [5.7; 9.5] | 18.4 | [15.6; 21.5] | 1.6 | [0.9; 2.6] | |
ncc, Unweighted sample size with complete information for all variables; CI, confidence interval
Figure 1.
30-Day use in the 18- to 24-year age group. 30-Day prevalence of the use of conventional tobacco products (CT), alternative tobacco products, and tobacco alternatives in 1995–2021: e-cigarettes (including e-cigars, e-waterpipes, and e-pipes) surveyed from 2015 onwards, as well as waterpipe and heat-not-burn products from 2018 onwards. Exact values are shown in eTable 3 (1995–2012) and, from 2015, in eTable 6.
In all age groups, one can see a clear downward trend in the use of conventional tobacco products among men since 1995. Among women in the youngest and oldest age groups, the prevalence rises until 2003, but also significantly declines thereafter. The shares of conventional tobacco product users who additionally reported using alternative products between 2015 and 2021 are highest in the youngest age group and lowest in the oldest for both genders (Figures 1– 3). Conversely, between 34% and 77% of alternative product users in the total sample reported using conventional tobacco products, depending on the product. This share is overall lowest among individuals that smoked waterpipe and highest among users of heat-not-burn products (table 1). There were statistically significant differences between age groups in the percentages of exclusive use of the three alternative products, including use of at least one of the three alternatives (table 2). The percentage of users of at least one of the three alternatives in 2021 was:
Table 1. Percentages of the use of conventional tobacco products (CT) amongusers (aged 18–59 year) of alternative products in the 30 days prior to the survey by survey year.
| Product | Survey year | |||
| 2015 | 2018 | 2021 | ||
| Waterpipe | Total (n) | - | 510 | 469 |
| CT percentage | - | 33.9 | 35.3 | |
| [95% CI] | - | [29.5; 38.6] | [30.5; 40.3] | |
| Heat-not-burn products | Total (n) | - | 77 | 101 |
| CT percentage | - | 50.4 | 64.9 | |
| [95% CI] | - | [39.3; 61.5] | [54.2; 74.2] | |
| E-cigarettes | Total (n) | 152 | 224 | 288 |
| CT percentage | 76.8 | 63.1 | 52.9 | |
| [95% CI] | [69.3; 82.9] | [56.1; 69.6] | [46.3; 59.3] | |
| At least onealternative | Total (n) | 152 | 639 | 703 |
| CT percentage | 76.8 | 44.5 | 46.3 | |
| [95% CI] | [69.3; 82.9] | [40.0; 49.2] | [42.2; 50.5] | |
E-cigarettes (including e-cigars, e-waterpipes, and e-pipes) surveyed from 2015 onwards, as well as waterpipe and heat-not-burn tobacco products from 2018 onwards; CI, confidence interval, n, unweighted
Table 2. 30-Day prevalence of the exclusive use of alternative tobacco products (waterpipe, heat-not-burn tobacco products) and tobacco alternatives (e-cigarettes) by age group, gender, and survey time point.
| Age | ||||||
| 18–24 Years | 25–39 Years | 40–59 Years | ||||
| 2018 | 2021 | 2018 | 2021 | 2018 | 2021 | |
| Women (n) | 1133 | 1156 | 1423 | 1543 | 1712 | 1801 |
| Prevalence | 9.6 %*2,*3 | 11.1 %*2,*3 | 1.7 %*1,*3 | 2.9 %*1,*3 | 0.4 %*1,*2 | 1.4 %*1,*2 |
| [95% CI] | [7.9; 11.6] | [9.2; 13.3] | [1.2; 2.5] | [2.1; 3.8] | [0.2; 1.0] | [0.9; 2.2] |
| Men (n) | 971 | 932 | 1174 | 1196 | 1369 | 1298 |
| Prevalence | 16.0 %*2,*3 | 12.4 %*2,*3 | 4.5 %*1,*3 | 4.9 %*1,*3 | 1.6 %*1,*2 | 2.0 %*1,*2 |
| [95% CI] | [13.5; 18.8] | [10.4; 14.8] | [3.4; 6.0] | [3.8; 6.5] | [1.0; 2.5] | [1.3; 3.1] |
E-cigarettes also include e-cigars, e-waterpipes, and e-pipes; statistically significant differences betweenage groups within a survey year were calculated using Pearson’s χ2 tests (α = 0.05). CI, confidence interval; n, unweighted
*1 Significant difference to 18–24 age group
*2 Significant difference to 25–39 age group
*3 Significant difference to 40–59 age group
11.1% among 18- to 24-year-old women and 12.4% among their male counterparts
2.9% among 25- to 39-year-old women and 4.9% among their male counterparts
1.4% among 40- to 59-year-old women and 2.0% among their male counterparts.
The use of alternative tobacco products among 18- to 24-year-olds and 25- to 39-year-olds primarily consists of the exclusive use of waterpipe, while in the oldest age group it consists of the exclusive use of e-cigarettes.
Discussion
The analyses of the trend over time in the use of tobacco and alternative products show a decline in the use of conventional tobacco products in all age groups. With regard to the use of waterpipes, heat-not-burn products, and e-cigarettes, significantly higher prevalence rates of use can be seen among young adults of both genders in 2018 and 2021 compared to the middle-age or oldest age groups. The high proportion of waterpipe users among young adults primarily accounts for the use of alternative products. The percentages of e-cigarette use are low, while heat-not-burn products play an insignificant role.
The reported prevalence rates of alternative product use among young adults are similar to those reported in the drug affinity study (20). A recent estimate of the prevalence of e-cigarette use in the 18- to 24-year-old age group in the DEBRA study suggests a lower rate at 2.4% (25). Estimates on waterpipe use are only available for the 11- to 14-year-old age group for the period 2014–2017 (23). However, at 8.5% (current use), they are significantly higher compared to the estimate for young adults in our study, indicating that waterpipe use is highly popular among adolescents. The estimates available on the use of heat-not-burn products are also very low, indicating low uptake of these products (20, 21).
The results suggest that health risks from the use of alternative tobacco products and tobacco alternatives are on the rise particularly among young adults. With regard to alternative products, there are three different forms of use, all with varying health effects, as previously mentioned. The diversification of tobacco consumption and tobacco alternatives gives rise to potential health risks over and above those already known from the use of conventional cigarettes (7, 14, e4). The health effects of the use of heat-not-burn products are still largely unresearched. However, they are irrelevant for the purposes of the current overall risk assessment since the share of these products in total consumption is low.
Both e-cigarettes and waterpipes deliver nicotine, meaning that these products have the potential to cause physical dependence (26, 27). The various e-cigarette products differ significantly in terms of their ability to deliver nicotine—depending on the characteristics of the device, the concentration and form of nicotine in the liquid, as well as the intensity of inhalation (28). In a study involving young-adult e-cigarette users, 28% of those surveyed exhibited at least one symptom of dependence (29). The type of device and flavor of the first e-cigarette used were associated with dependence symptoms. Young adults that used a mint/menthol flavored e-cigarette, as well as those that used a newer-generation e-cigarette (for example, mods), were more likely to report symptoms of nicotine dependence compared to users of tobacco, fruit, or other flavored e-cigarettes and users of older-generation e-cigarettes (29). Average waterpipe use of 30–60 min results in the user being exposed to 1.7 times more nicotine compared to smoking a cigarette (30). Nicotine absorption resulting from daily waterpipe use is equivalent to smoking 10 conventional cigarettes (31). It has been shown that the symptoms of nicotine dependence following waterpipe use are identical to those associated with cigarette smoking. However, adolescent waterpipe smokers developed symptoms of nicotine dependence earlier than did adolescent conventional-cigarette smokers. On the other hand, they had less difficulty discontinuing use compared to cigarette smokers (32).
The popularity of these alternative tobacco products and tobacco alternatives can be put down to the marketing of the products using flavors, the perception that their use is socially acceptable, and the belief that these products are less harmful to health than conventional cigarettes (33). Also, the ban on waterpipes and e-cigarettes is not as wide as that on conventional cigarettes. After many years spent trying to denormalize smoking, venues such as lounges where the use of alternative tobacco products and tobacco alternatives is permitted have been socially acceptable and gaining popularity for some time (33).
It is anticipated for the future that the rate of nicotine dependence will increase and the use of alternative products will continue, and that more smokers will make the switch to conventional tobacco products or will use both types of products. A European study reported that, comparable to our results, 52.6% of e-cigarette users smoked conventional cigarettes (34). If the trend remains constant, one can assume that the rise in the use of alternative products alongside the simultaneous decline in the use of conventional tobacco products will largely coincide with the aging of the age cohorts affected today. It is uncertain here whether the existing tobacco prevention and control measures will be able to stop this trend. The new challenges include the rise in nicotine dependence, the potential for switching from alternative to conventional products, and the unknown health risks associated with the long-term use of alternative products.
Since millions of smokers in middle and later adulthood in Germany are at risk for future tobacco-related morbidity and mortality, differentiated tobacco prevention and control measures, which also take into account the potential of e-cigarettes to achieve smoking cessation, are needed (16, 20, 35). For adolescents and young adults, more intensive preventive measures, such as comprehensive and objective risk disclosure, are needed. Furthermore, environmental preventive measures that limit the availability of alternative products are also needed. These include banning the sale of flavored products (liquids for e-cigarettes and tobacco for waterpipes), putting limits on the concentration of nicotine, tax increases, and banning the advertising of these products (36, 37).
Limitations
Survey-based prevalence rates of use are generally underestimated due to the socially desirable response behavior of respondents and possible differences in information on use between respondents and nonrespondents; nevertheless, they are a satisfactory representation of consumption behavior (38). If one assumes that external influences remain constant in repeated cross-sectional surveys, biases in response behavior do not play a significant role in the analysis of trends over time, since it is the trend and not the absolute prevalence that is of interest. The ESA managed to avoid differences arising for methodological reasons by using comparable sampling methods. Since alternative products were not added until 2015, changes over time can only be observed from this point onwards. Although it is extremely likely that the prevalence rates of use of these products were lower before 2015 (e-cigarettes) and 2018 (waterpipes and heat-not-burn products), one can assume for young adults that the the prevalence of alternative product use increased at an earlier point in time.
Summary
The recently observed increase in the use of alternative tobacco products and e-cigarettes among young adults implies a turning point that needs to be considered in tobacco prevention efforts. Although assessments of the health risks of these products vary, an increase in negative health effects can be expected. This affects primarily young adults, and one can assume that this group will continue to use alternative products into their middle and older adulthood, will switch to conventional tobacco products, or will use both. As a result, the prevalence of use as a whole will also increase in these age groups. Against the backdrop of a possible paradigm shift, the tobacco industry is expecting up to 50% of its net profit to be generated by noncombustible products by as early as 2025 (39). Therefore, tobacco prevention efforts need to concentrate as much on the risks of alternative products as on those of conventional tobacco products (40). At the same time, health policy considerations should not ignore the potential of e-cigarettes to achieve smoking cessation among highly dependent adults.
Supplementary Material
eMethods section
Survey instruments (ESA) for the use of conventional tobacco products, alternative tobacco products, and tobacco alternatives in the period 1995–2021
Instruments and analysis
The use of relevant products at least once in the 30 days prior to the survey was taken into consideration. The use of conventional tobacco products such as cigarettes, cigars, cigarillos, or pipes has been surveyed since 1995. Data on the use of alternative products have been available for e-cigarettes (including e-waterpipes, e-pipes, and e-cigars) since 2015, as well as for waterpipes (hookahs) and heat-not-burn products since 2018. The respective questionnaires can be found at www.esa-survey.de/studie/instrumente.html. The references to the individual study protocols are listed in eTable 1.
Since use is surveyed by means of several questions, missing values are replaced in part through logical imputation. For example, if only information on quantity in the preceding 30 days was provided, missing information on the time of last use (lifetime, 12-month, and 30-day prevalence) was substituted accordingly. For the analysis, only complete information for all products was used. An overview of missing values per wave can be found in eTable 2.
Conventional tobacco products
The survey has included questions on conventional tobacco products since 1995. In the survey waves of 1995 and 1997, only respondents that answered the question “Would you describe yourself as a smoker, an occasional smoker, or a non-smoker?” with “smoker” and “occasional smoker” were asked about their use in more detail. The use of conventional tobacco products was surveyed using the following questions:
From the 2000 survey wave onwards, smokers were identified using the following questions:
From 2003 onwards, question 2 was modified to “Have you smoked more than a total of 100 cigarettes/cigars/cigarillos/pipes in your life?” Using the question “What do you mainly smoke” or “What did you mainly smoke in the past?”, smokers of conventional tobacco products were identified based on the answer categories: 1. “cigarettes,” 2. “cigars,” 3. “cigarillos,” 4. “pipe.” From 2006 onwards, the question was modified to “What do you smoke, or if you no longer smoke, what did you mainly smoke in the past?”
Alternative tobacco products and tobacco alternatives
The use of alternative tobacco products and tobacco alternatives was surveyed by means of the question “Have you ever used a waterpipe (hookah), a heat-not-burn product, or an e-cigarette/e-cigar/e-waterpipe/e-pipe? If yes, when was the last time you used this?” The possible answers included: 1. “In the last 30 days,” 2. “in the last 12 months,” 3. “longer ago,” and 4. “no, never used one of these.”
Users of tobacco alternatives were limited to users of nicotine-containing e-cigarettes. In response to the question “Do you use or have you used e-cigarettes/e-cigars/e-waterpipes/e-pipes with or without nicotine?”, respondents could select one of the following categories: 1. “exclusively without nicotine,” 2. “mainly without nicotine,” 3. “mainly with nicotine,” 4. “mainly with nicotine,” 5. “exclusively with nicotine,” or 6. “both.” Users of e-cigarettes in the “exclusively without nicotine” category were not considered as e-cigarette users for the purposes of the analyses.
“When did you last smoke?” (Answer categories: 1. “today,” 2. “yesterday,” 3. “the day before yesterday,” or state the elapsed time in days, weeks, months or years)
“Have you smoked within the previous 30 days (4 weeks/1 month).” (Answer categories: “yes”/“no”)
“What do you smoke?” (Answer categories: 1. “cigarettes,” 2. “cigars/cigarillos,” or 3. “pipe tobacco”)
“Do you currently smoke?” (Answer categories: “yes”/“no,” or from 2012 onwards: 1. “yes, regularly,” 2. “yes, occasionally,” 3. “no”)
“In the past, have you ever smoked more than 100 cigarettes/cigars/cigarillos/pipes?” (Answer categories: 1. “yes” or 2. “no, never”)
Figure 2.
30-Day use in the 25- to 39-year age group. 30-Day prevalence of the use of conventional tobacco products (CT), alternative tobacco products, and tobacco
alternatives in 1995–2021: e-cigarettes (including e-cigars, e-waterpipes, and e-pipes) surveyed from 2015 onwards, as well as waterpipe and heat-not-burn products from 2018 onwards. Exact values are shown in eTable 4 (1995–2012) and, from 2015, in eTable 6.
Figure 3.
30-Day use in the 40- to 59-year age group. 30-Day prevalence of the use of conventional tobacco products (CT), alternative tobacco products, and tobacco
alternatives in 1995–2021: e-cigarettes (including e-cigars, e-waterpipes, and e-pipes) surveyed from 2015 onwards, as well as waterpipe and heat-not-burn products
from 2018 onwards. Exact values are shown in eTable 5 (1995–2012) and, from 2015, in eTable 6.
eTable 4. Sample size and 30-day prevalence [95% confidence interval] of the use of conventional tobacco products and alternative products (from 2015) by survey year and gender; age 25–39 years.
| Conventional tobacco | E-cigarette | Waterpipe | Heat-not-burn product | |||||||
| Survey year | ncc | % | 95% CI | % | 95% CI | % | 95% CI | % | 95% CI | |
| Women | 1995 | 1882 | 37.0 | [34.5; 39.5] | – | – | – | – | – | – |
| 1997 | 1877 | 36.6 | [33.5; 39.9] | – | – | – | – | – | – | |
| 2000 | 1728 | 33.8 | [31.7; 36.0] | – | – | – | – | – | – | |
| 2003 | 1590 | 32.1 | [29.7; 34.6] | – | – | – | – | – | – | |
| 2006 | 1268 | 29.1 | [26.3; 32.0] | – | – | – | – | – | – | |
| 2009 | 1477 | 28.9 | [26.9; 30.9] | – | – | – | – | – | – | |
| 2012 | 1396 | 24.6 | [22.4; 26.9] | – | – | – | – | – | – | |
| 2015 | 1455 | 24.6 | [22.5; 27.0] | 0.8 | [0.5; 1.3] | – | – | – | – | |
| 2018 | 1423 | 19.3 | [16.7; 22.2] | 1.6 | [1.0; 2.7] | 1.8 | [1.3; 2.7] | 0.2 | [0.1; 0.7] | |
| 2021 | 1543 | 17.1 | [15.2; 19.3] | 2.2 | [1.5; 3.3] | 2.7 | [2.0; 3.6] | 1.5 | [1.0; 2.3] | |
| Men | 1995 | 1365 | 47.2 | [44.2; 50.3] | – | – | – | – | – | – |
| 1997 | 1493 | 47.7 | [44.2; 51.3] | – | – | – | – | – | – | |
| 2000 | 1294 | 41.9 | [39.2; 44.7] | – | – | – | – | – | – | |
| 2003 | 1198 | 38.9 | [35.7; 42.1] | – | – | – | – | – | – | |
| 2006 | 932 | 40.1 | [36.9; 43.4] | – | – | – | – | – | – | |
| 2009 | 1125 | 38.0 | [35.1; 41.0] | – | – | – | – | – | – | |
| 2012 | 890 | 35.9 | [32.8; 39.3] | – | – | – | – | – | – | |
| 2015 | 1132 | 30.0 | [27.3; 32.8] | 3.0 | [2.2; 4.1] | – | – | – | – | |
| 2018 | 1174 | 25.3 | [22.8; 27.9] | 3.9 | [2.9; 5.4] | 6.1 | [4.8; 7.7] | 1.1 | [0.6; 1.9] | |
| 2021 | 1196 | 25.0 | [22.5; 27.8] | 4.2 | [3.3; 5.4] | 5.5 | [4.3; 7.1] | 1.3 | [0.8; 2.2] | |
ncc, Unweighted sample size with complete information for all variables; CI, confidence interval
eTable 5. Sample size and 30-day prevalence [95% confidence interval] of the use of conventional tobacco products and alternative products (from 2015) by survey year and gender; age 40–59 years.
| Conventional tobacco | E-cigarette | Waterpipe | Heat-not-burn product | |||||||
| Survey year | ncc | % | 95% CI | % | 95% CI | % | 95% CI | % | 95% CI | |
| Women | 1995 | 1992 | 21.5 | [19.6; 23.6] | – | – | – | – | – | – |
| 1997 | 1960 | 22.9 | [20.5; 25.5] | – | – | – | – | – | – | |
| 2000 | 2118 | 25.1 | [22.9; 27.5] | – | – | – | – | – | – | |
| 2003 | 1737 | 27.0 | [24.6; 29.5] | – | – | – | – | – | – | |
| 2006 | 1608 | 26.5 | [24.2; 28.9] | – | – | – | – | – | – | |
| 2009 | 1453 | 24.0 | [21.9; 26.4] | – | – | – | – | – | – | |
| 2012 | 1990 | 24.5 | [22.4; 26.8] | – | – | – | – | – | – | |
| 2015 | 1834 | 23.3 | [21.5; 25.4] | 1.2 | [0.8; 1.8] | – | – | – | – | |
| 2018 | 1712 | 17.5 | [15.6; 19.7] | 0.6 | [0.3; 1.1] | 0.5 | [0.2; 1.0] | 0.2 | [0.0; 0.6] | |
| 2021 | 1801 | 16.9 | [15.1; 18.8] | 2.2 | [1.5; 3.1] | 0.6 | [0.3; 1.2] | 1.2 | [0.7; 1.9] | |
| Men | 1995 | 1800 | 35.8 | [33.3; 38.4] | – | – | – | – | – | – |
| 1997 | 1781 | 38.9 | [35.7; 42.1] | – | – | – | – | – | – | |
| 2000 | 1938 | 34.9 | [32.5; 37.3] | – | – | – | – | – | – | |
| 2003 | 1577 | 34.4 | [31.9; 37.1] | – | – | – | – | – | – | |
| 2006 | 1278 | 34.5 | [31.9; 37.2] | – | – | – | – | – | – | |
| 2009 | 1180 | 31.0 | [28.4; 33.7] | – | – | – | – | – | – | |
| 2012 | 1543 | 27.8 | [25.7; 30.0] | – | – | – | – | – | – | |
| 2015 | 1395 | 26.4 | [24.2; 28.8] | 1.7 | [1.2; 2.6] | – | – | – | – | |
| 2018 | 1369 | 23.4 | [21.0; 26.0] | 2.2 | [1.5; 3.3] | 1.3 | [0.7; 2.4] | 0.8 | [0.4; 1.6] | |
| 2021 | 1298 | 21.9 | [19.6; 24.5] | 2.7 | [1.9; 3.8] | 0.9 | [0.5; 1.6] | 1.1 | [0.6; 2.0] | |
ncc, Unweighted sample size with complete information for all variables; CI, confidence interval
eTable 6. 30-Day prevalence (%) of the use of conventional tobacco products (CT), alternative products, and tobacco alternatives in the period 2015–2021 by gender and age.
|
Age
(years) |
Survey year | CT |
CT and at least
one alternative |
Waterpipe |
Heat-not-burn
product |
E-cigarette |
More than one
alternative |
|
| Women | 18–24 | 2015 | 18.3 | 1.1 | – | – | 0.7 | – |
| 2018 | 11.7 | 5.6 | 7.4 | 0.0 | 0.7 | 1.4 | ||
| 2021 | 10.0 | 5.5 | 7.7 | 0.2 | 0.8 | 2.4 | ||
| 25–39 | 2015 | 24.1 | 0.6 | – | – | 0.2 | – | |
| 2018 | 17.6 | 1.7 | 1.3 | 0.0 | 0.4 | 0.1 | ||
| 2021 | 14.4 | 2.7 | 1.8 | 0.4 | 0.4 | 0.3 | ||
| 40–59 | 2015 | 22.5 | 0.9 | – | – | 0.3 | – | |
| 2018 | 16.9 | 0.6 | 0.4 | 0.0 | 0.0 | 0.1 | ||
| 2021 | 14.8 | 2.1 | 0.4 | 0.4 | 0.5 | 0.0 | ||
| Men | 18–24 | 2015 | 26.2 | 2.2 | – | – | 0.8 | – |
| 2018 | 14.4 | 9.2 | 10.9 | 0.1 | 0.7 | 4.3 | ||
| 2021 | 12.8 | 9.2 | 7.4 | 0.1 | 1.0 | 4.0 | ||
| 25–39 | 2015 | 27.8 | 2.2 | -– | – | 0.8 | – | |
| 2018 | 20.7 | 4.5 | 2.6 | 0.1 | 1.0 | 0.8 | ||
| 2021 | 20.2 | 4.8 | 2.7 | 0.5 | 1.0 | 0.8 | ||
| 40–59 | 2015 | 24.9 | 1.5 | – | – | 0.2 | – | |
| 2018 | 21.7 | 1.7 | 0.5 | 0.1 | 0.5 | 0.4 | ||
| 2021 | 20.0 | 1.9 | 0.4 | 0.1 | 1.2 | 0.3 | ||
E-cigarettes (including e-cigars, e-waterpipes, and e-pipes) surveyed from 2015 onwards, hookah (waterpipe), and heat-not-burn products from 2018 onwards. Disjoint user groups are shown
Acknowledgments
Translated from the original German by Christine Rye.
Footnotes
Funding
The 2021 German Epidemiological Survey of Substance Abuse (ESA) was funded by the German Federal Ministry of Health (Bundesministerium für Gesundheit, BMG) (Ref. No.: ZMVI1–2520DSM203).
Conflict of interest statement
The authors declare that no conflict of interests exists.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods section
Survey instruments (ESA) for the use of conventional tobacco products, alternative tobacco products, and tobacco alternatives in the period 1995–2021
Instruments and analysis
The use of relevant products at least once in the 30 days prior to the survey was taken into consideration. The use of conventional tobacco products such as cigarettes, cigars, cigarillos, or pipes has been surveyed since 1995. Data on the use of alternative products have been available for e-cigarettes (including e-waterpipes, e-pipes, and e-cigars) since 2015, as well as for waterpipes (hookahs) and heat-not-burn products since 2018. The respective questionnaires can be found at www.esa-survey.de/studie/instrumente.html. The references to the individual study protocols are listed in eTable 1.
Since use is surveyed by means of several questions, missing values are replaced in part through logical imputation. For example, if only information on quantity in the preceding 30 days was provided, missing information on the time of last use (lifetime, 12-month, and 30-day prevalence) was substituted accordingly. For the analysis, only complete information for all products was used. An overview of missing values per wave can be found in eTable 2.
Conventional tobacco products
The survey has included questions on conventional tobacco products since 1995. In the survey waves of 1995 and 1997, only respondents that answered the question “Would you describe yourself as a smoker, an occasional smoker, or a non-smoker?” with “smoker” and “occasional smoker” were asked about their use in more detail. The use of conventional tobacco products was surveyed using the following questions:
From the 2000 survey wave onwards, smokers were identified using the following questions:
From 2003 onwards, question 2 was modified to “Have you smoked more than a total of 100 cigarettes/cigars/cigarillos/pipes in your life?” Using the question “What do you mainly smoke” or “What did you mainly smoke in the past?”, smokers of conventional tobacco products were identified based on the answer categories: 1. “cigarettes,” 2. “cigars,” 3. “cigarillos,” 4. “pipe.” From 2006 onwards, the question was modified to “What do you smoke, or if you no longer smoke, what did you mainly smoke in the past?”
Alternative tobacco products and tobacco alternatives
The use of alternative tobacco products and tobacco alternatives was surveyed by means of the question “Have you ever used a waterpipe (hookah), a heat-not-burn product, or an e-cigarette/e-cigar/e-waterpipe/e-pipe? If yes, when was the last time you used this?” The possible answers included: 1. “In the last 30 days,” 2. “in the last 12 months,” 3. “longer ago,” and 4. “no, never used one of these.”
Users of tobacco alternatives were limited to users of nicotine-containing e-cigarettes. In response to the question “Do you use or have you used e-cigarettes/e-cigars/e-waterpipes/e-pipes with or without nicotine?”, respondents could select one of the following categories: 1. “exclusively without nicotine,” 2. “mainly without nicotine,” 3. “mainly with nicotine,” 4. “mainly with nicotine,” 5. “exclusively with nicotine,” or 6. “both.” Users of e-cigarettes in the “exclusively without nicotine” category were not considered as e-cigarette users for the purposes of the analyses.
“When did you last smoke?” (Answer categories: 1. “today,” 2. “yesterday,” 3. “the day before yesterday,” or state the elapsed time in days, weeks, months or years)
“Have you smoked within the previous 30 days (4 weeks/1 month).” (Answer categories: “yes”/“no”)
“What do you smoke?” (Answer categories: 1. “cigarettes,” 2. “cigars/cigarillos,” or 3. “pipe tobacco”)
“Do you currently smoke?” (Answer categories: “yes”/“no,” or from 2012 onwards: 1. “yes, regularly,” 2. “yes, occasionally,” 3. “no”)
“In the past, have you ever smoked more than 100 cigarettes/cigars/cigarillos/pipes?” (Answer categories: 1. “yes” or 2. “no, never”)